This is an ECG I performed a couple of years ago on an asymptomatic 83-year old man as an outpatient procedure.
The computer interpreted this as: "Marked sinus bradycardia [with] Frequent Premature ventricular complexes". IS THE COMPUTER CORRECT? Is there more than one plausible interpretation? What is the differential diagnosis?
This is an ECG I performed on a 65-year old man about 5 years ago. He mentioned something to me about his past medical history before we got started but, in truth, I would have recognized it had he not told me beforehand. What did he tell me and what does this ECG reveal?
Patient data: 54-year old man who recently underwent a major cardiac procedure. At first glance, this ECG may not appear to be particularly unique but a closer inspection reveals something unusual going on here.
The only patient data I have is that this ECG is from a 73-year old man. At the request of the site administrator (Dawn Altman), I'm posting this ECG because there isn't one quite like it in the Guru's archives. Some readers will recognize it as one I recently posted on another website. This one lives up to the title of "Challenging". I'll make the same general statement I did on the other website: You'll need to make careful measurements with calipers on this ECG to come to the correct interpretation.
This is a normal sinus rhythm with atrial bigeminy, a term meaning that every other beat is a PAC. If you look carefully, you can see slight differences in the sinus P waves and the atrial (premature) P waves. The PACs penetrate and reset the sinus node, causing what looks like a delay after the PAC. It is often just a return to the normal P to P interval, or nearly so. If you teach basic students in a clinical setting, they will learn from palpating the peripheral pulse and feeling the pattern of bigeminal beats. Sometimes, the premature beat feels much weaker due to less filling time available to the ventricles. Atrial bigeminy can have very benign causes, such as increased caffeine intake, or it can have more complex causes such as advanced heart disease or conduction blocks. In some patients, atrial bigeminy, or any PACs, can be a precursor to more serious atrial dysrhythmias, such as atrial fibrillation.
Here is a nice example of sinus tachycardia taken from a 2-year-old in the post-anesthesia care unit after a short GI endoscopic procedure. Would you call this NSR, since it is from a child? The pre-op heart rate in this child was 120/min.
For your more advanced students, remind them that, in adults especially, a heart rate close to 150/min. should cause them to examine the ECG in several leads, looking for the presence of atrial flutter with 2:1 conduction. Another important teaching point, most ADULTS with sinus tach at 150/min. would manifest an obvious reason for the rapid heart rate (dehydration, pain, anxiety, shock, etc.) Challenge your basic students to come up with as many causes for sinus tach as they can.
